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Citation history
Health deficiencies cited at Parkview Julian Healthcare Center during CMS and state inspections, most recent first.
A resident experienced multiple falls, and post-fall assessments documented specific interventions such as not leaving the resident unattended in a W/C, use of a floor mat, frequent staff monitoring, ensuring the call light was within reach, checking vitals, and providing safety education during transitional movements. Although these interventions were recorded on Therapy Post-Fall Screens and the falls were documented as changes of condition, the DON confirmed that the high-risk fall care plan was not updated to include these measures, contrary to facility policy requiring IDT review of post-fall assessments and revision of the care plan as indicated.
A resident with severe cognitive impairment, total dependence for toileting, chronic incontinence, and a high fall risk score was not managed in accordance with the facility’s Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline. During a night shift, a CNA observed a wet brief and offered incontinence care, which the resident refused; the CNA did not notify the LVN, did not seek assistance, and did not recheck or re-offer care for nearly two hours, and the resident’s brief was not checked and changed every two hours as required. Later that shift, the CNA found the resident partially off the bed attempting to go to the bathroom, with a wet and soiled brief, and the nurse and CNA assisted the resident back to bed. Subsequent imaging identified a periprosthetic distal femur fracture, and the resident later underwent surgical repair.
A RN documented respiratory distress symptoms for a resident in error, recording observations such as difficulty breathing and sternal retractions that were meant for another individual. The DON confirmed that nursing documentation must be accurate, as per facility policy.
A resident's grievances regarding food preferences and noise were not properly addressed, as the facility failed to inform the resident of the investigation outcomes or actions taken. Documentation was incomplete, with missing signatures and notifications, and staff confirmed that required follow-up and communication did not occur, contrary to facility policy.
A resident who is fully dependent on staff for toileting hygiene reported waiting up to 40 minutes for assistance after using the call light, despite a history of UTIs. A CNA confirmed that high resident assignments sometimes delay responses to call lights, contrary to facility policy requiring prompt attention.
A resident who managed his own finances experienced repeated unapproved charges on his bank card by a family member. Despite staff awareness and documentation of the financial abuse, the incident was not reported or investigated as required by policy, and no care plan was developed to protect the resident or address his refusal of protection.
A resident with Alzheimer's disease and a high fall risk experienced a fall resulting in a right hip fracture after staff failed to follow the care plan interventions, which included placing a floor mat on the right side of the bed and ensuring the use of nonskid socks. Documentation and staff interviews confirmed that these interventions were not in place at the time of the incident, despite being clearly outlined in the care plan.
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not timely submitting required reports to the CDPH and local ombudsman for two residents involved in incidents. Additionally, the facility did not notify the attending physician or develop a care plan for a resident who experienced financial abuse, contrary to policy requirements.
A resident in a LTC facility did not receive an antibiotic as prescribed by the MD for a surgical wound infection. The Treatment Nurse entered the order incorrectly, administering Keflex every eight hours instead of four times a day. The DON confirmed the inaccuracy, and the facility's policy requires complete and accurate medication orders.
A facility failed to follow its policy on resident weight management for a resident with mild protein-calorie malnutrition, who did not have his weight taken for three months. Despite multiple meal refusals and discomfort with the hoyer lift, no alternative weight measurement methods were used, and the issue was not discussed by the Interdisciplinary Team. The Dietary Manager confirmed that the Quarterly Nutrition Review was inaccurate due to outdated weight data.
A resident was not involved in the care planning process when the facility changed the method of transferring him from his bed to the shower bed. The resident was not informed of the reason for the change, and there was no documentation of a discussion with him prior to the care plan initiation. This failure violated the resident's rights as outlined in the facility's policy.
A resident missed a necessary doctor's appointment for valley fever treatment due to the facility's failure to schedule transportation. The appointment was noted in the resident's order details, but the Social Services Department did not receive a transportation request, which is required for scheduling. The facility's policy indicates that the Social Services Department assists with transportation arrangements, but this was not executed, leading to the missed appointment.
A resident with moderate cognitive impairment was not monitored for respiratory distress after a fire in her room, despite experiencing throat and lung pain, chest pain, and difficulty breathing. The facility's care plan required alert charting and monitoring of vital signs every shift for 72 hours, but this was not documented or conducted, as confirmed by a nurse consultant.
A facility failed to log and timely process medical records requests for three residents, violating its policies on resident access to PHI and third-party disclosures. The requests were delayed by 20 to 31 days, despite a policy requiring action within five days.
The facility failed to properly inventory and secure personal items of two residents upon admission, leading to the presence of dangerous materials like lighters and cigarettes in their possession. Staff confirmed that smoking materials should be stored securely, but this was not done, resulting in a deficiency.
The facility failed to ensure that several residents had signed and dated Advance Directives (ADs) in their medical records, and did not document that other residents were informed about their right to complete an AD. This oversight involved multiple residents whose ADs were either unsigned, undated, or missing entirely, potentially impacting the honoring of their healthcare wishes.
The facility did not complete smoking assessments for several residents who smoked independently, as required by their policy. This failure involved incomplete or delayed assessments for multiple residents, posing a potential safety risk.
A facility failed to administer medications as per physician orders for a resident, with missing documentation for Normal Saline Flush and Unasyn. Key staff lacked current CPR certification, and the facility did not provide required educational programs to all staff, impacting patient care and safety. Additionally, a Maintenance Technician was unaware of policies, leading to unapproved space heaters in residents' rooms.
The facility failed to ensure a safe environment for residents, leading to several deficiencies. A resident at risk for choking was left unsupervised with sugar packets, while ten residents who smoked were not monitored, contrary to facility policy. Additionally, two residents had unauthorized space heaters, and a resident at risk for wandering had an unalarmed door, posing potential safety hazards.
The facility failed to notify the Ombudsman of hospital transfers for two residents, as required by their policy. This was confirmed through record reviews and staff interviews, revealing that no notifications were made for transfers occurring in several instances.
A cook in the facility failed to follow the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth, potentially compromising the nutritive value of meals for residents on a pureed diet. The facility's policy requires adherence to approved recipes to conserve nutritive value, which was not followed in this instance.
The facility failed to maintain sanitary food storage and preparation practices. Expired baking soda, a dented can, and unlabeled and undated food items were found in the dry storage room, freezer, and refrigerator. These deficiencies were confirmed by staff, who acknowledged non-compliance with the facility's policies.
The report highlights deficiencies in facility safety and maintenance, including a water-stained ceiling with mold, unauthorized space heaters in residents' rooms, and a non-functional alarm on a sliding glass door for a resident at risk of elopement. The Maintenance Supervisor was unaware of the water damage, and the Administrator had not approved the space heaters, while the DON confirmed the resident's elopement risk.
A facility failed to complete the informed consent process for a resident receiving Amitriptyline, a psychotherapeutic medication. During a review, it was discovered that the informed consent form lacked a signature of verification, indicating the process was incomplete. This was contrary to the facility's policy, which mandates obtaining informed consent before administering medical interventions requiring it.
The facility failed to maintain a homelike environment for a resident and two other residents. A resident's clothing was damaged due to improper laundering, resulting in bleach stains. Additionally, two residents' rooms had unpainted drywall patches, broken baseboards, and peeling wallpaper, as confirmed by a maintenance technician.
The facility failed to follow its dialysis care procedures for two residents with chest catheters. One resident lacked an order for monitoring her dialysis access site, and both residents were incorrectly assessed for bruit and thrill, which are not applicable for chest catheters. The facility's policy outlines procedures for AV shunts or fistulas, which neither resident had.
The facility failed to complete required PASRR evaluations for two residents. One resident's PASRR Level I screening indicated a positive result for SMI, but the facility did not respond to communication attempts, resulting in an incomplete assessment. Another resident's positive Level I screening required a Level II evaluation, which was not conducted. The facility did not follow its policy requiring in-depth evaluations for positive Level I screens.
A resident on IV antibiotics for osteomyelitis did not receive two doses of Unasyn due to a staffing mix-up, resulting in no registered nurse coverage for a shift. The facility's policy requires sufficient nursing staff to meet resident needs, which was not met in this case.
Two residents were served meals that did not align with their documented preferences, leading to dissatisfaction and an outburst. The facility's policy required adherence to food preferences, but both residents were served Mac and Cheese despite disliking pasta, as confirmed by the CDM.
A resident with a BIMS score of 15, indicating no cognitive impairment, was not provided coffee, their preferred beverage, throughout the day, despite their care plan indicating a need to maintain hydration. Staff, including the Dietary Supervisor and CNAs, did not accommodate the resident's requests, citing a lack of process for beverage preferences outside meal times. The facility's policy stated that resident preferences should be adhered to within reason, but this was not followed.
The facility failed to ensure the Director of Staff Development (DSD) met the required qualifications, as she had only a year and a half of nursing experience instead of the required two years. This discrepancy was confirmed by the Director of Nurses (DON) and had the potential to impact the DSD's ability to provide adequate education to the nursing staff, potentially affecting residents' health and safety.
The facility failed to follow physician's orders for two residents, leading to potential health risks. One resident received an incorrect dosage of Seroquel, while another did not receive a recommended speech therapy evaluation after a choking incident. Both the LVN and DON confirmed these discrepancies.
A facility failed to monitor behaviors for a resident prescribed Quetiapine fumarate for behavior management, leading to potential unnecessary psychotropic medication use. The Director of Nursing confirmed the absence of behavior monitoring records, and an LVN stated that behaviors should be documented in the MAR. The facility's policy required daily monitoring of target behaviors, which was not followed.
The facility failed to conduct timely care planning meetings for a resident, with the most recent care conference completed in July 2023 and subsequent required conferences in October 2023 and January 2024 not conducted. This lapse was confirmed by the Social Services Director and was against the facility's policy, potentially leading to unmet care needs.
A resident did not receive Klonopin and Seroquel as prescribed, with no documentation of administration, refusal, or holding of the medications. This was confirmed by the MDS Nurse during an interview and record review.
Failure to Update Care Plan With Post-Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan with fall-related interventions identified after two separate falls. Review of the resident’s Therapy Post-Fall Screens (TPFS) showed that after a fall dated 11/1/25, the TPFS documented that the resident should not be left unattended in a wheelchair, required frequent staff monitoring, a floor mat, and a call light within reach at all times. A subsequent TPFS following another fall dated 3/7/26 documented the need for a floor mat, frequent staff monitoring, vital sign checks, and education of the resident about safety during transitional movements. These specific recommendations were recorded on the TPFS forms but were not incorporated into the resident’s high-risk for falls care plan. During an interview and concurrent record review with the DON, it was confirmed that the resident’s Change of Condition forms dated 11/1/25 and 3/7/26 were both related to falls that occurred while the resident was in bed. The DON reviewed the resident’s high-risk fall care plan and acknowledged that the TPFS recommendations from 11/1/25 and 3/9/26 had not been added to the care plan, despite the facility’s policy titled “Response to Falls.” That policy requires that after each fall, a licensed nurse complete a post-fall assessment and investigation, and that the IDT/Falls Committee review the post-fall assessment within 72 hours to consider changes in the plan of care and revise the resident’s care plan as necessary. The DON stated that falls are reviewed during standup and that the missed updates to the resident’s high-risk fall care plan should have been identified and made at that time.
Failure to Follow Fall, Refusal of Treatment, and Continence Policies for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline for a resident with severe cognitive impairment and a history of falls. The resident had diagnoses including generalized muscle weakness, need for assistance with personal care, history of falling, and a prior displaced intertrochanteric fracture of the right femur with surgical intervention. The MDS documented that the resident was wheelchair-bound, totally dependent for toileting hygiene, unable to stand, walk, or transfer to the toilet, and always incontinent of bowel and bladder. The resident’s fall risk evaluation score of 17 indicated a high fall risk, and the care plan identified risk for repeated falls related to deconditioning, gait/balance problems, psychoactive drug use, generalized weakness, prior mechanical fall with right femur fracture, impulsive behavior, and episodes of crawling out of bed, with an intervention to anticipate and meet the resident’s needs. On the night in question, CNA 1 reported that during the 10 p.m. to 6:30 a.m. shift, she checked the resident at approximately 3:30 a.m. and observed that the brief’s wetness indicator had changed color, indicating the brief was wet. CNA 1 stated she offered to change the resident’s brief, but the resident refused. Despite this refusal, CNA 1 did not notify the LVN or the charge nurse as required by the facility’s Refusal of Treatment policy, did not seek assistance from another CNA to help with changing the resident, and did not return to re-offer or attempt to change the brief for the next one hour and 45 minutes. CNA 1 also stated that during that entire night shift she changed the resident only once, after the fall, and did not check and change the resident’s brief every two hours as required by the facility’s Continence Management Guideline, explaining that the resident usually refused at night. At around 5:15 a.m., CNA 1 passed by the resident’s room and saw the resident holding the bed rail with one leg bent on the floor mat; the resident stated she was trying to go to the bathroom to urinate. CNA 1 checked the resident’s brief and found it wet with bowel movement. LVN 1, who was passing medications at that time, was called to the room and observed the resident with most of her hip on the bed and her legs hanging off the bed; LVN 1 and CNA 1 assisted the resident to the ground and then back to bed, and LVN 1 documented that the resident initially had no pain or visible injury. Subsequent imaging on 12/29 showed a periprosthetic distal femur fracture of indeterminate age, and by 12/31 the resident had developed right knee swelling and pain, leading to hospital evaluation where CT imaging confirmed a periprosthetic distal femoral metaphyseal fracture, followed by surgical repair with retrograde intramedullary nailing on 1/3. The facility’s Fall Management Program policy required assisting patients with toileting as appropriate, which was not carried out in accordance with the resident’s identified needs and risk factors. These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur fracture (broken bone) requiring hospitalization and surgery.
Inaccurate Nursing Documentation for Resident Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for one resident when a Registered Nurse (RN) incorrectly recorded respiratory distress symptoms, including difficulty breathing, shallow respirations, sternal retractions, and shortness of breath while lying flat, in the resident's Nurse Advance Skilled Evaluation. During a review, the RN acknowledged that the documentation was entered in error and was actually intended for another, unidentified resident. The Director of Nursing (DON) confirmed that nursing documentation should be accurate, as outlined in the facility's policy and procedure for nursing documentation, which requires records to be concise, clear, pertinent, and accurate. This inaccuracy in documentation had the potential to result in inappropriate care for the resident, as the recorded symptoms did not reflect the resident's actual condition at the time.
Failure to Inform Resident of Grievance Outcomes
Penalty
Summary
The facility failed to follow its grievance policy and procedure for one resident who reported multiple concerns, including issues with food preferences and excessive noise from a roommate's television. The resident stated that after requesting to speak with the administrator and kitchen staff regarding these concerns, no one had come to address them. Review of the Resident Grievance/Complaint Investigation Reports showed that while the complaints were documented, there was no evidence that the resident was informed of the outcome of the investigations or any actions taken to resolve the grievances. Key sections of the reports, such as signatures, dates, and notifications to the concerned party, were left blank. Interviews with facility staff, including the DON, confirmed that grievances are routed to the Social Services Director and then to the responsible department, with the administrator ultimately responsible for ensuring investigation, resolution, and communication of outcomes to the resident. However, documentation revealed that no follow-up with the resident was recorded, and the required sign-offs were missing. The facility's policy requires that residents be informed of the findings and corrective actions in a timely manner, which was not done in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to accommodate a resident's needs by not ensuring timely response to call lights. During an interview, a resident reported having to wait up to 40 minutes after using the call light to be changed following a bowel movement. The resident, who is cognitively intact and fully dependent on staff for toileting hygiene, also reported a history of urinary tract infections since admission. Review of the resident's Minimum Data Set confirmed her dependence for toileting hygiene. A Certified Nursing Assistant (CNA) stated that she is sometimes responsible for up to 17 residents during her shift and may be delayed in responding to call lights when attending to other residents. The facility's policy requires nursing staff to answer call bells promptly and courteously. However, the observed delays in responding to the resident's call light requests indicate that this policy was not consistently followed.
Failure to Report and Investigate Financial Abuse and Develop Protective Care Plan
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not reporting and investigating the misappropriation of a resident's property to the California Department of Public Health and the local ombudsman. A resident, who was cognitively intact and managed his own finances, reported that his brother had made unapproved charges on his bank card after being given permission to use a limited amount. Despite multiple incidents of unapproved charges by the brother, staff did not report or investigate the situation, as the resident did not wish to press charges and was aware of his brother's actions. Interviews with staff, including the Behavioral Health Worker, Social Services Director, and Administrator, confirmed that the resident's brother had repeatedly used the resident's bank card without full approval. The Social Services Director and Administrator acknowledged the unapproved charges but did not initiate an investigation or report the incident, citing the resident's reluctance to take action against his brother. Documentation in the resident's social services notes indicated awareness of the financial abuse and discussions with the resident about the risks and benefits, but no formal reporting or investigation occurred as required by facility policy. Additionally, the facility did not develop or implement a care plan to protect the resident from further financial abuse, nor did it address the resident's refusal to be protected from his brother. The Director of Nursing confirmed that no care plans were created or updated in response to the financial abuse incidents. The facility's care planning policy requires comprehensive, person-centered care plans to address changes in a resident's condition or behavior, but this was not followed in this case.
Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to follow the individualized care plan for a resident with Alzheimer's disease, hemiplegia, muscle weakness, and a high risk for falls. The care plan specifically required the use of a floor mat on the right side of the bed and ensuring the resident wore nonskid socks when getting out of bed. Multiple assessments and evaluations, including the Minimum Data Set and Fall Risk Evaluation, identified the resident as severely cognitively impaired and at high risk for falls, necessitating these interventions. Despite these documented interventions, records and interviews revealed that on several occasions, including the incident in question, the required floor mat was not in place and the resident was not wearing nonskid socks. On the day of the fall, the resident was found on the floor on the right side of the bed, without a floor mat and barefoot. Staff interviews confirmed a lack of awareness of the resident's fall risk status and the specific interventions outlined in the care plan. Previous post-fall evaluations also documented instances where the floor mat was missing and appropriate footwear was not used. As a result of these failures to implement the care plan, the resident sustained a fall resulting in a right hip intertrochanteric fracture, requiring hospitalization and surgical intervention. The facility's own policy emphasized the importance of developing and following a comprehensive, person-centered care plan based on assessed needs, but this was not adhered to in the resident's case.
Failure to Report and Address Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Prohibition Program policy, resulting in several deficiencies. The Director of Nursing (DON) confirmed that the facility did not submit the SOC 341 form to the California Department of Public Health (CDPH) and the local ombudsman for two residents involved in an unwitnessed altercation. This lapse in communication led to a delay in reporting the incident. Additionally, the facility did not submit a 5-day investigation report to the local ombudsman and CDPH for another resident who was a victim of financial abuse, exceeding the required timeline. Furthermore, the facility did not notify the attending physician of the financial abuse allegation concerning the same resident, leaving the physician unaware of the situation. The facility also failed to develop a care plan to address the resident's mental or psychosocial needs following the discovery of financial abuse. These actions were contrary to the facility's policy, which mandates immediate reporting of abuse allegations and reassessment of residents to update care plans as necessary.
Failure to Administer Antibiotic as Prescribed
Penalty
Summary
The facility failed to ensure that an antibiotic order was administered as prescribed by the Medical Doctor for a resident. The resident was admitted for surgical aftercare and was prescribed Keflex to treat a surgical wound infection. The Medication Administration Record indicated that the resident received Keflex every eight hours from February 13 to February 20, contrary to the Medical Doctor's order of four times a day for ten days. During an interview, the Treatment Nurse acknowledged entering the Keflex order incorrectly and not following the Medical Doctor's orders. The Director of Nursing confirmed that the Keflex order was inaccurate. The facility's policy and procedure for physician orders require that all medication orders include the name, dosage, frequency, duration, route, and condition/diagnosis for which the treatment is ordered, which was not adhered to in this case.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the assessment and management of resident weights, specifically for one resident who did not have his weight taken for three months. This oversight was identified during a review of the resident's records, which showed that the last recorded weight was from several months prior. The resident, diagnosed with mild protein-calorie malnutrition, had multiple meal refusals documented over the course of January, which could have impacted his nutritional status. Despite these refusals and the resident's condition, no alternative methods for weight measurement were employed, and the resident's weight was not discussed by the Interdisciplinary Team during this period. Interviews with the Dietary Manager and Director of Nursing revealed that the facility's Quarterly Nutrition Review was inaccurate due to outdated weight data. The resident expressed that he refused to be weighed at times because the hoyer lift caused discomfort, yet no alternative methods were offered. The facility's policy required weights to be taken upon admission and then regularly thereafter, but this was not followed. The Director of Nursing acknowledged that alternative methods, such as measuring arm circumference, were not utilized, and the resident's refusal to be weighed was not addressed by the Interdisciplinary Team.
Resident Not Involved in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was involved in the comprehensive person-centered care planning process, resulting in a violation of the resident's rights. The resident, who had been transferred via sheet from his bed to the shower bed since January 2024, was informed by facility staff that this method of transfer would no longer be used. The resident was not given a reason for this change, and there was no documentation of a discussion with the resident regarding the change in transfer method. During interviews and record reviews, it was revealed that the facility's Administrator and Director of Nursing were unable to provide documentation of any discussion with the resident about the change in transfer method prior to the initiation of the care plan on December 21, 2024. The facility's policy on resident rights, revised in November 2017, states that residents have the right to participate in decisions and care planning and to be fully informed of their treatment. The lack of documentation and failure to involve the resident in the care planning process led to the deficiency.
Failure to Schedule Transportation for Resident's Doctor Appointment
Penalty
Summary
The facility failed to ensure that transportation was scheduled for a resident's necessary doctor's appointment, resulting in the resident missing the appointment. The resident, who was being treated for valley fever, a serious lung infection, had an appointment scheduled on December 16, 2024, as indicated in the order details dated December 4, 2024. However, the social services note from the same day indicated that transportation was not arranged, leading to the appointment being rescheduled. Interviews with the Social Services Director and the Director of Nursing revealed that the transportation request was not received by the Social Services Department, which is responsible for scheduling transportation. The Director of Nursing confirmed that the nurses are responsible for entering the order into the resident's medical record and filling out a transportation request to be given to the Social Services Director. The facility's policy on referrals to outside services states that the Social Services Department may assist in making transportation arrangements as necessary, but this process was not followed, resulting in the missed appointment.
Failure to Implement Care Plan After Fire Incident
Penalty
Summary
The facility failed to implement a care plan for a resident following a fire incident in the resident's room. The resident, who had moderate cognitive impairment, experienced throat and lung pain, chest pain, and difficulty breathing after inhaling smoke from the fire. Despite these symptoms, the facility did not monitor the resident for respiratory distress as required. The resident reported that the nurses did not monitor her after the fire, which occurred on December 21, 2024. The facility's care plan for the resident, dated December 21, 2024, indicated that the resident should be placed on alert charting to assess any changes in medical condition, with vital signs, including oxygen saturation and respiration, checked every shift for 72 hours. However, a review of the resident's medical records revealed no documentation of alert charting or monitoring of vital signs from December 21 to December 23, 2024. The nurse consultant confirmed that the required monitoring was not conducted, which was a deviation from the facility's care planning policy.
Failure to Log and Timely Process Medical Records Requests
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding resident access to protected health information (PHI) for three of four sampled residents. Specifically, the medical records requests (MRR) for these residents were not logged, which is a requirement according to the facility's policy titled 'Resident Access to PHI.' This policy mandates that the facility document the date of the request, the employee addressing the request, the date of the facility's response, the action taken, and whether a review of the facility's initial response was requested. During an interview and record review, the Medical Records (MR) staff confirmed that no log was maintained for the MRRs of the three residents, potentially leading to delays in reviewing and acting upon these requests. Additionally, the facility did not comply with its policy titled 'Third Party Disclosures of Protected Health Information,' which requires timely action on communication requests. The MRRs for the three residents were not sent to the requesting office within the required timeframe, with delays ranging from 20 to 31 days. The policy specifies that requests for PHI by a resident's attorney prior to filing a lawsuit should be addressed within five days. The failure to act upon these requests in a timely manner resulted in a violation of the residents' rights to have their MRRs processed promptly.
Failure to Inventory and Secure Residents' Personal Items
Penalty
Summary
The facility failed to ensure that personal items of two residents were properly inventoried upon admission, which led to the potential for unaccounted personal items and the presence of dangerous materials. During observations and interviews, it was found that one resident had a lighter and cigarettes on his bedside table, which he stated he was allowed to keep upon admission. A Certified Nursing Assistant confirmed the presence of these items and stated that residents should not have lighters or smoking materials in their possession, as they should be stored in a locked box with a nurse or activity staff. Another resident also had smoking materials, including a lighter, which were not properly inventoried or secured as per the facility's smoking policy. The facility's staff, including a Registered Nurse and a Licensed Vocational Nurse, confirmed that the smoking policy and procedure were explained to residents upon admission, and that a personal inventory should be completed to track residents' belongings and ensure safety. However, the inventory for one resident did not document the presence of a lighter or cigarettes, and there was no documentation of a refusal to search the resident's bag. The facility's policy indicated that all smoking materials should be stored securely, but this was not adhered to, leading to the deficiency.
Failure to Ensure Proper Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that six of the twenty sampled residents had a signed and dated Advance Directive (AD) in their medical records. During interviews and record reviews, it was found that the ADs for these residents were either unsigned or undated. Specifically, the Social Service Director (SSD) confirmed that the ADs for Residents 58, 87, 193, 22, 17, and 70 were present in their medical records but lacked necessary signatures and dates. This oversight could potentially lead to situations where the residents' healthcare wishes are not honored in emergency medical situations. Additionally, the facility did not document that five of the twenty sampled residents were informed about their right to complete an Advance Directive or had evidence of declining to complete one. The SSD confirmed that there were no ADs in the medical records of Residents 344, 4, 68, 60, and 45, nor was there documentation indicating that these residents were informed of their rights regarding ADs. The facility's policy requires that upon admission, staff should obtain a copy of a resident's AD or inform them of their right to complete one, which was not adhered to in these cases.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking assessments for residents who smoke independently on the smoking patio. Specifically, the facility did not complete smoking assessments for ten out of eleven sampled residents, which is a requirement to ensure safety while smoking. The Minimum Data Set Coordinator acknowledged that a smoking assessment should have been conducted upon re-admission for Resident 42, but it was not completed until a later date. This oversight was consistent across multiple residents, as their smoking assessments were either incomplete or not conducted in a timely manner. The facility's policy, dated February 1, 2022, mandates that all smokers be assessed for smoking safety at the time of admission and at least quarterly. However, the review of smoking assessments for several residents, including Residents 17, 24, 42, 43, 62, 78, 89, 243, and 245, revealed that the assessments were either incomplete or not conducted according to the policy. This failure to perform timely and complete smoking assessments resulted in residents not being evaluated for safety while smoking, posing a potential risk of burns or other injuries.
Medication Administration and Staff Training Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to physicians' orders for a resident, identified as Resident 82. The IV Medication Administration Record (MAR) for Resident 82 showed multiple instances where there was no documentation of the administration of Normal Saline Flush and Unasyn, a medication used to treat infection. The Director of Nursing confirmed the lack of documentation for these medications on specific dates, which could potentially lead to the worsening of the resident's infection. The facility's policy requires that medications be administered by a licensed nurse per the physician's order and documented accordingly, which was not adhered to in this case. Additionally, the facility did not ensure that three key staff members, including a Registered Nurse, the Director of Staff Development, and the Director of Nursing, had current CPR certification. The personnel files reviewed showed expired or missing CPR certifications, which is against the facility's policy that mandates all clinical staff to maintain active CPR certification. This oversight could potentially hinder the staff's ability to perform life-saving procedures during emergencies. Furthermore, the facility failed to provide the required educational programs to its staff, including 57 Certified Nursing Assistants and 27 Licensed Nurses. The Director of Staff Development was unable to provide sign-in sheets or documentation for various mandatory training topics, such as infection control, patient rights, and safety measures. This lack of training documentation suggests that not all staff received the necessary education to perform their duties effectively, which could impact patient care and safety. Additionally, the Maintenance Technician was unaware of the facility's policy regarding the use of personal space heaters, resulting in two residents having unapproved heaters in their rooms.
Deficiencies in Supervision and Safety Measures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for several residents, leading to multiple deficiencies. One resident, who was at risk for choking, was left unsupervised in the dining room and was observed putting sugar packets into her mouth and chewing on them. This resident had a severely impaired cognitive ability, as indicated by her Minimum Data Set, and her care plan specifically noted a behavior of eating non-food items, with an intervention to remove unnecessary paper items from meal trays. Additionally, the facility did not adequately supervise residents who smoked. Ten residents who smoked were not monitored with smoking materials and were allowed to smoke unsupervised, contrary to the facility's policy that required all smoking activities to be scheduled and supervised by staff. Smoking materials were found in residents' possession, and some residents were observed smoking without supervision. The facility's policy stated that all smoking materials should be locked up, and residents who could not smoke independently should be accompanied by staff, but these protocols were not followed. Furthermore, two residents had space heaters in their rooms without authorized approval, posing a potential fire hazard. The facility's policy required the administrator's approval for electrical appliances, and the administrator confirmed that no space heaters were authorized. Another resident, who was at risk for wandering and elopement, had an unlocked and unalarmed sliding glass door in her room, which could have allowed her to leave the facility unnoticed. The facility's policy required functioning alarms for residents at risk of elopement, but this was not adhered to in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of the Ombudsman during resident transfers. Specifically, the facility did not send a notice of transfer to the Ombudsman for two residents, Resident 42 and Resident 50, when they were transferred to the hospital. This oversight was identified during a review of Resident 42's medical record, which showed transfers on three separate occasions without any indication of Ombudsman notification. An interview with the Minimum Data Set Coordinator confirmed that no Ombudsman notification was done for these hospital transfers. Similarly, for Resident 50, transfer forms dated September and October indicated hospital transfers, but there were no corresponding Ombudsman notifications. This was confirmed during a review of the facility's transfer/discharge binder, where the Social Services Director acknowledged the absence of Ombudsman notifications for those months. The facility's policy, dated April 2024, clearly states that a copy of the Notice of Proposed Transfer/Discharge must be provided to the Ombudsman at the same time it is given to the resident or their representative, which was not followed in these instances.
Deviation from Pureed Food Recipe
Penalty
Summary
The facility failed to adhere to its policy and procedure for food preparation, specifically in the preparation of pureed meals. During an observation and interview, a cook was found to have deviated from the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth. This deviation occurred while preparing meals for residents on a pureed diet, potentially compromising the nutritive value of the food provided to them. The facility's policy, dated 2023, mandates that food be prepared using methods that conserve nutritive value, flavor, and appearance, and that approved recipes be followed precisely. The cook acknowledged the error during a review of the recipe, which clearly indicated the use of specific fluids to maintain the nutritional integrity of the meal. This oversight in following the recipe could lead to nutritive impairment for residents requiring a pureed diet.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to maintain food storage and preparation areas in a sanitary manner, as observed during a survey. In the dry storage room, 11 boxes of baking soda were found to be expired, and a dented can of Pork and Beans was improperly stored with regular canned goods. Additionally, a plastic bag of dry pasta noodles was found unlabeled and undated. These observations were confirmed by a staff member, who acknowledged that the items should have been properly labeled, dated, and stored according to the facility's policy and procedures. Further deficiencies were noted in the kitchen's freezer and refrigerator. An unlabeled and undated bag of hash browns was found in the freezer, and in the refrigerator, pitchers of red and brown liquids, as well as glasses of milk and juices, were also unlabeled and undated. The facility's policy requires all food items in storage areas to be labeled and dated, and all prepared foods to be covered, labeled, and dated. The staff member confirmed these items were not in compliance with the facility's policy.
Facility Safety and Maintenance Deficiencies
Penalty
Summary
The report identifies several deficiencies related to the safety and maintenance of the facility. In one instance, a water stain with black mold was observed on the ceiling above a resident's bed, indicating a potential leak. The Maintenance Supervisor acknowledged the water damage but found no documentation of staff notifying him about the issue, despite the facility's standard operating procedures highlighting the health risks associated with excessive moisture and mold. Additionally, space heaters were found in the rooms of two residents without the necessary approval from the Administrator, who stated that such appliances are not allowed due to fire risks. Furthermore, a resident identified as a wanderer and at risk for elopement had an unlocked sliding glass door with a non-functional alarm, contrary to the care plan and facility policy. The Director of Nursing confirmed the resident's risk status and the requirement for a functioning alarm to ensure safety.
Incomplete Informed Consent for Psychotherapeutic Medication
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informed consent for psychotherapeutic medication for one of the sampled residents. During an interview and record review, it was found that the informed consent for a resident receiving Amitriptyline, a medication used to treat symptoms of depression, was incomplete. The Minimum Data Set Coordinator (MDSC) confirmed that the signature of verification on the informed consent form was blank, indicating that the consent process was not completed. This oversight occurred despite the facility's policy requiring verification of informed consent prior to administering any medical intervention that necessitates such consent.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as evidenced by issues with laundry services and room maintenance. Resident 17 experienced damage to personal clothing due to improper laundering, resulting in bleach stains and the need to discard several shirts. During an interview, the laundry services staff acknowledged that clothing might not have been sorted correctly, leading to bleach damage. Additionally, the rooms of Residents 62 and 75 were found to have unaddressed maintenance issues, including unpainted drywall patches, broken baseboards, and peeling wallpaper. These conditions were observed during interviews with a maintenance technician, who confirmed that the building required significant cosmetic repairs. These deficiencies contributed to an environment that was not homelike for the affected residents.
Failure to Follow Dialysis Care Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dialysis Care' for two residents, resulting in deficiencies in monitoring and assessing dialysis access sites. Resident 69, who had a dialysis catheter on her chest, did not have an order for monitoring her dialysis access site, and the type of access was not documented in her Order Summary Report. Additionally, the staff incorrectly assessed for bruit and thrill, which are not applicable for a chest catheter, as they are typically associated with an arteriovenous (AV) shunt or fistula in the arm. Similarly, Resident 67, who also had a dialysis catheter on her chest, was subjected to inappropriate assessments for bruit and thrill, as documented in her Progress Notes. The facility's policy specifically outlines the procedure for assessing an AV shunt or fistula, which neither resident had. These actions indicate a failure to provide accurate and appropriate care for the residents' dialysis access sites, as the staff did not follow the established procedures for the type of dialysis access the residents had.
Failure to Complete PASRR Evaluations for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for Pre-Admission Screening and Resident Review (PASRR), resulting in deficiencies for two residents. For Resident 68, the PASRR Level I screening indicated a positive result for Serious Mental Illness (SMI), but the facility did not respond to multiple communication attempts within 48 hours, leading to an incomplete assessment and failure to resubmit the PASRR. This inaction prevented the necessary Level II evaluation from being conducted, as required by the facility's policy. Similarly, for Resident 69, the PASRR Level I screening also indicated a positive result, necessitating a Level II Mental Health Evaluation. However, the facility did not conduct the required Level II evaluation. The facility's policy clearly states that a positive Level I screen requires an in-depth evaluation by the state-designated authority before admission to a nursing facility, which was not followed in these cases.
Inadequate Staffing Leads to Missed Medication Doses
Penalty
Summary
The facility failed to ensure adequate staffing to meet the care plan needs of a resident, specifically in administering necessary medications. Resident 82, who was on IV antibiotics for osteomyelitis related to the right foot and ankle, did not receive two scheduled doses of Unasyn on October 27, 2024. The care plan required the administration of antibiotics as per the medical doctor's orders, but the IV Medication Administration Record (IV MAR) showed no documentation of the 6 a.m. and 12 p.m. doses being administered on that day. During an interview and record review with the Director of Nursing (DON), it was revealed that the facility experienced a scheduling mix-up and was unable to secure registered nurse coverage for the day shift on October 27, 2024. This staffing issue directly led to the missed doses of medication for Resident 82. The facility's policy on staffing, which was reviewed, mandates that sufficient nursing personnel be available to meet resident needs, but this was not adhered to in this instance.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preference' by not honoring the meal preferences of two residents, Resident 24 and Resident 43. During an observation and interview, it was noted that Resident 24 was served Mac and Cheese for lunch, despite her documented dislike for pasta. The Certified Dietary Manager (CDM) confirmed that Resident 24's Meal Tray Ticket (MTT) indicated a dislike for pasta, and acknowledged that Mac and Cheese should not have been served to her. Similarly, Resident 43 was also served Mac and Cheese, which was against his documented meal preference as indicated on his MTT. This led to an angry outburst from Resident 43. The CDM confirmed that Resident 43's MTT also indicated a dislike for pasta, and acknowledged the error in serving him Mac and Cheese. The facility's policy stated that residents' food preferences should be adhered to within reason, and substitutes for disliked foods should be provided from the appropriate food group.
Failure to Accommodate Resident Beverage Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations and follow the care plan for a resident, leading to potential dehydration and poor oral moisture and skin elasticity. The resident expressed dissatisfaction with not being able to receive coffee, their preferred beverage, throughout the day. Despite the resident's requests, staff members, including the Dietary Supervisor and Certified Nursing Assistants, did not provide coffee, citing reasons such as the kitchen being closed or not having a process to accommodate beverage preferences outside of meal times. The resident's care plan indicated a potential fluid deficit and the need to maintain hydration, yet the facility did not adhere to this plan. The Director of Nursing acknowledged that beverage provision should be based on resident choice, especially for residents with a BIMS score of 15, indicating no cognitive impairment. The facility's policy on food preferences stated that resident preferences should be adhered to within reason, but this was not followed in the case of the resident's coffee preference.
DSD Lacks Required Nursing Experience
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) met the required qualifications for the position, specifically having a minimum of two years of experience as a Licensed Nurse. During an interview and record review, it was revealed that the DSD received her Licensed Vocational Nurse (LVN) license in February 2023 and had only about a year and a half of nursing experience by the time she started working as a DSD in June 2024. This lack of experience did not meet the job qualifications outlined in the DSD's job description, which required a minimum of two years of experience as a Licensed Nurse in supervision and providing care in a long-term care facility. The Director of Nurses (DON) confirmed during an interview that the job description for the DSD position indeed required two years of nursing experience. The failure to meet this requirement had the potential to impact the DSD's ability to provide adequate education to the nursing staff, which could negatively affect the residents' health and safety. The report highlights the discrepancy between the DSD's qualifications and the job requirements, emphasizing the importance of adhering to established criteria for such critical roles within the facility.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to potential adverse health concerns. For Resident 1, the physician's order dated 4/5/24 indicated a change in the dosage of Quetiapine Fumarate (Seroquel) from 50 mg to 75 mg to be administered in the afternoon for aggression. However, upon review on 5/20/24, it was found that Resident 1 was still receiving the 50 mg dosage in the evening, with three doses missing from the medication card. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that Resident 1 was not receiving the correct dosage as per the updated physician's order. For Resident 2, a Change in Condition Evaluation (COCE) dated 5/26/24 noted symptoms of choking, with a recommendation for a speech therapy evaluation (STE). However, during a review on 6/14/24, the DON was unable to provide documentation that the STE had been completed, acknowledging that it should have been done. The facility's policy on Telephone Orders for Medication, dated 11/1/17, outlines the procedure for documenting orders, but it appears this was not followed in these instances.
Failure to Monitor Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors were monitored for one of the sampled residents, leading to the potential for unnecessary psychotropic medication administration. Resident 1 was prescribed Quetiapine fumarate, an antipsychotic medication, for behavior management. However, during a review of Resident 1's care plan, it was found that there was no documentation of behavior monitoring. The Director of Nursing confirmed the absence of behavior monitoring records and acknowledged that Resident 1's behaviors should have been monitored. Additionally, a Licensed Vocational Nurse stated that behaviors should be documented in the Medication Administration Record when residents are on psychotropic medications. The facility's policy on psychotherapeutic drug management required daily monitoring of target behaviors, charting by exception, which was not adhered to in this case.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to ensure that care planning meetings for a resident were completed in a timely manner. Specifically, the care conference for a resident admitted on an unspecified date was not conducted as required. The most recent care conference for this resident was completed on 7/13/23, but subsequent conferences that should have been held in October 2023 and January 2024 were not conducted. This lapse was confirmed during an interview and record review with the Social Services Director (SSD) on 3/6/24 at 12:40 p.m. The facility's policy and procedure (P&P) titled 'Care Planning,' dated 11/1/17, mandates that the Interdisciplinary Team (IDT) develop a comprehensive care plan within 7 days after the completion of the comprehensive admission assessment. The care plan must be periodically reviewed and revised by a team of qualified personnel after each assessment, including comprehensive and quarterly review assessments. The SSD confirmed that the care conferences were not completed as per the facility's policy, which had the potential for the resident to have unmet care needs.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to administer ordered medications for one of three sampled residents. Specifically, Resident 1 did not receive Klonopin and Seroquel as prescribed. The Klonopin, ordered to manage severe manic symptoms associated with bipolar disorder, was not documented as administered on 2/22/24 at 5 p.m. Similarly, the Seroquel, prescribed for schizoaffective disorder, was not documented as administered on 2/22/24 at 9 a.m. and 9 p.m. These omissions were confirmed by the Minimum Data Set Nurse during an interview and record review on 3/6/24 at 11:52 p.m. The facility's policy and procedure for medication administration, revised on 11/1/2017, requires that medications be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. The policy also mandates that any refusal or holding of medication be documented appropriately on the Medication Administration Record (MAR). In this case, there was no documentation indicating that the medications were administered, refused, or held, which is a deviation from the established policy. The Minimum Data Set Nurse confirmed these findings during the review.
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All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 176 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Health Facility | 2.6 mi | — | 16 | 0 |
| Valley Healthcare Center | 2.8 mi | — | 26 | 0 |
| The Orchards Post-acute | 4.2 mi | — | 2 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 4.8 mi | — | 17 | 0 |
| The Rehabilitation Center Of Bakersfield | 5.3 mi | — | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.